Investigation Summary
The accident occurred during a private flight arranged by a third party to transport Emiliano Sala from Nantes to Cardiff following his transfer to Cardiff City F.C. The pilot, David Ibbotson, was operating under Visual Flight Rules (VFR) at night despite having no night flying rating and an expired rating for the PA-46. During the flight, the pilot requested a descent to maintain visual conditions as weather deteriorated. Post-mortem toxicology on Sala revealed a carboxyhemoglobin (COHb) level of 58 percent, indicating severe carbon monoxide poisoning. The AAIB concluded that CO leaked into the cabin through the heating system, which draws air over the engine exhaust. This likely impaired the pilot's ability to fly the aircraft safely in challenging conditions. The aircraft entered a high-speed descent and broke apart before impacting the water. The wreckage was located on the seabed at a depth of approximately 67 meters.
Final Conclusions
The AAIB final report (AAR 1/2020) concluded that the pilot lost control of the aircraft during a manually-flown turn to avoid or regain visual conditions. The aircraft broke up in flight because it was maneuvered at speeds significantly exceeding its design limits. A primary factor was the pilot's probable impairment due to carbon monoxide poisoning. Contributory factors included the pilot's lack of night and instrument flying experience, the absence of an active CO detector in the cabin, and the failure to operate the flight under the stricter safety standards required for commercial air transport.
Photographic Evidence (1)
Video Analysis
No video analysis linked for this case file yet.
Systems & Failure Modes
Exhaust and Heating System
The cabin heat in the PA-46 is provided by air passing over the engine exhaust manifold; a leak in the exhaust allowed carbon monoxide to enter the cabin air supply.
Secondary Surveillance Radar (SSR)
The aircraft's transponder provided altitude and position data until 20:16 GMT, after which only primary radar returns were visible.
Interesting Facts
- 01The pilot's private pilot license did not permit him to carry passengers for profit.
- 02The pilot's rating for the Piper PA-46 had expired in November 2018.
- 03Post-mortem tests on the passenger showed a carboxyhemoglobin level of 58 percent.
- 04The aircraft was not equipped with a carbon monoxide detector that provided an active warning.
- 05The flight organizer, David Henderson, was later sentenced to 18 months in prison for endangering the safety of an aircraft.
- 06Both the pilot and passenger expressed concerns about the aircraft's mechanical condition via messages prior to the flight, with the pilot describing the aircraft as 'falling to pieces'.
Safety Actions & Advisories
Legal to Fly Campaign
The UK Civil Aviation Authority published a leaflet to help the public identify and avoid unlicensed 'grey' air charter operations.
CO Detector Recommendations
The AAIB recommended that regulators require the carriage of CO detectors with active audible or visual warnings in piston-engine aircraft.